Views

The hidden influence on the Shape of Training

By:
Benjamin J F Dean

Medical education and postgraduate medical training in the United Kingdom have undergone much government reorganisation in recent years. The most recent structural upheavals came in the form of Modernising Medical Careers and the Medical Training Application Service, whose rushed introduction in 2007 led to a protest march by doctors, national news headlines, professorial resignations, and ministerial apologies. This personal perspective on the Shape of Training review sits in the context of this history, showing how these past events have quickly been forgotten and important lessons ignored.[1]

The independent Shape of Training review aimed to look at the current and future healthcare needs of patients in the United Kingdom and how medical training can match these needs. The Shape of Training review steering group (including the four UK health departments, Health Education England, National Education Scotland, and other major professional medical organisations) appointed David Greenaway, professor of economics at the University of Nottingham, as chair in February 2012. The review’s recommendations were published at the end of 2013 and included proposals to train more generalist doctors, introduce shorter training programmes, and change the point of full General Medical Council (GMC) registration for medical graduates.

I began to develop concerns around the review’s assumptions and methodology when I read some of the early material released on the review’s website. It seemed to me that the review tried to sum up qualitative feedback quantitatively. I also believed that the review set up a false dichotomy between generalists and specialists, when the reality is that many consultants are somewhere in between. These reservations prompted me to find out more about the genesis of these recommendations and to submit a freedom of information request to the GMC in July 2013 to find out if meetings had taken place between the review’s chair and government ministers which were not disclosed in the review’s final report. Initially, the GMC refused the request under section 36 of the Freedom of Information Act (this means the GMC’s view was that release would “inhibit free and frank discussion”), but they did disclose that meetings had been held between senior politicians and civil servants throughout the review. The information commissioner refused my initial appeal against the GMC’s decision to withhold documentation about these meetings. However, in December 2014 I successfully appealed to the General Regulatory Chamber. The court stated that it was “strongly in the public interest that these proposals are made on the basis of sound criteria and any political influence or otherwise needs to be transparent.”[2] In one meeting, senior officials from the Department of Health revealed that government ministers were “setting strategic direction and feeling happy,”[3] before the review had completed its oral evidence sessions or analysed the written evidence. The GMC ended up spending more than £4000 on legal fees in resisting my freedom of information requests.

What this revelation has exposed is a worrying lack of transparency[2] about the review’s dealings with ministers and civil servants, which is a concern because the outcomes and recommendations of the review will directly affect the future careers of medical students and doctors in training.

Of particular relevance to medical students is the proposal to move the point of full GMC registration to graduation from medical school, rather than after one year practising as a junior doctor. The review states: “This change will inevitably have a knock on effect on undergraduate medical education, which will have to ensure graduates meet more advanced outcomes.” The review does not explain how this will be achieved, let alone why it is being introduced in the first place. Another implication of this change would be that almost double the number of European Economic Area graduates would be able to apply in open competition for the UK foundation programme.[4] The implications of this change for the future employment of domestic medical graduates have also yet to be clarified.

Another recommendation from the review proposes to shorten the amount of time given to train consultants, but this is at odds with the views of most respondents who were interviewed. Meeting patients’ needs and delivering them safely must be at the forefront of any changes to the training of doctors—shortening training time seems a strange way to achieve this.

Doctors in training have not been listened to during the consultation, and yet we, as well as our patients, are the ones who will be most affected. It is concerning that there has been no explanation as to why the meetings with both senior politicians and civil servants were not documented within the review’s formal paper trail. It is also notable that without my freedom of information request we may not have known about the existence of these meetings or what role they had in “setting strategic direction.”

I would urge that if any of you have concerns after reading this, then please get involved, help raise awareness among your colleagues, and write to your member of parliament—every little really does help. More than 6500 individuals have signed a petition to halt the review’s implementation process.[5] The review’s steering group recently responded to some of the criticisms squared at the review, but there was no specific mention of the main safety concern: the recommendation to shorten the training time of hospital consultants.[6] Patient safety must be given more priority and any changes to training time must include the robust measurement of patient outcomes using only well validated and sensitive measures.